Provider Demographics
NPI:1568879591
Name:CDCR/CIM
Entity Type:Organization
Organization Name:CDCR/CIM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF MENTAL HEALTH
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:909-606-7159
Mailing Address - Street 1:14901 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-9500
Mailing Address - Country:US
Mailing Address - Phone:909-606-7159
Mailing Address - Fax:909-606-7044
Practice Address - Street 1:14901 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-9500
Practice Address - Country:US
Practice Address - Phone:909-606-7159
Practice Address - Fax:909-606-7044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13916283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital